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Emergency / Crisis Handbook

Franklin-Grand Isle Mental Health

Revision: August 31, 1995 SDA crisisbk.doc

 

CONTENTS:

Adults
Suicidality
Emergency Room Consults
Phone Screenings
Med / Surg Consults
Police, Prison, & Court Consults
22 Upper Welden & Transitional Housing
After Hours Coverage
Children
Suicidal Statements, Danger to Self or Others
Family Difficulties / SRS
Schools
General

 

ADULTS

  1. Suicidality, Risk to harm self or others

    1. Assessment

      1. Ideation (Have you thought about hurting or killing yourself?)

      2. Intent (Is that something you think you might do?)

      3. Plan (What would you do?)

      4. History (Have you felt like this / done anything like that before?)

      5. Future Orientation (Where do you see yourself in a year?)

      6. SAD PERSONS (risk factors)

        1. Sex -- F more likely, M more lethal

        2. Age -- <19 and >45 considered risk factors

        3. Depression

        4. Previous Attempt

        5. Ethanol Abuse

        6. Rational Thinking

        7. Social Supports -- relatives, friends, work, church

        8. Organized Plan

        9. No Spouse

        10. Sickness

    2. Plan -- Should be clearly influenced by assessment

      1. Stay at home

        1. Client will need to be with someone who can stay with him/her and guarantee his/her safety, and they must agree to let you speak to this person so that you can review safety procedures

        2. Safety procedures

          1. Guns out of the home

          2. Medicines, knives, cleaners, etc. out of reach

          3. Eliminate or minimize major stressors as appropriate

        3. Obtain verbal or written no-harm contract (document!)

        4. Scheduled phone checks may be appropriate

        5. A rapid office follow-up appointment is appropriate

      2. Emergency/Respite Bed

        1. Appropriate if CT not safe at home but will be safe in a supervised, social setting and is familiar to FGIMH

        2. CT should be scheduled to go to AcuCare/IOP or an immediate Emergency/Crisis follow-up appointment

        3. AcuCare ("Day Hospital", "partial hospitalization") or Intensive Out Patient (IOP) is meant to help people who can be safe in the community but would require inpatient hospitalization were partial hospitalization not available

        4. This level of care, and the more drastic interventions (listed below), should be cleared with the psychiatrist on call

        5. At this time our respite bed facility is located at 22 Upper Welden. Availability of the respite bed and availability of staff to provide supervision needs to be cleared by Michael Bombard or Andrew Melcher.

      3. Voluntary Hospitalization

        1. Appropriate when CT unable to be safe at home or is not manageable at AcuCare/IOP

        2. Have history of presenting problem, preliminary diagnosis, demographic data (age, insurance, etc.), current symptoms, and a clear justification of your reasons for requesting hospitalization ready prior to calling hospitals

        3. Fletcher Allen Health Care (FAHC) in Burlington is first call.

          1. During business hours, ask for inpatient psych admitting (pager 409, Lisa Cutler, Suzanne, or Scott Perry). Locked unit is Smith 3, unlocked unit is Smith 4 - screeners will determine which is appropriate

          2. Tell the client if they are going to the "locked" unit and stress that this is still a voluntary admission

          3. After hours, ask for the psych resident on call. The resident often opts to re-evaluat CT in FAHC ER prior to admission, in which case we cannot guarantee admission after hours. New protocols allow for more rapid decisions, and are being implemented

        4. Next hospitals on list include CVH (Berlin), Rutland Hospital, CVPH (Plattsburgh), Dartmouth/Hitchcock, Cheshire Hospital.

        5. If CT is a veteran, VA in White River

        6. If you encounter delays (this is likely if a bed is not available at Fletcher Allen), it is advisable to place calls to a number of hospitals simultaneously, rather than waiting for a response from each

      4. Involuntary Hospitalization

        1. Only appropriate when CT refuses all community alternatives AND

        2. CT is an active danger to self or others AND

        3. CT has a diagnosis of a major mental illness

        4. CT must be involuntary

        5. You must be a screener designated by the Commissioner of Mental Health

        6. The patient must be evaluated by the psychiatrist on call, who must agree that an Emergency Evaluation ("E.E.") is necessary

        7. Call Vermont State Hospital and ask for admitting, provide information listed below in section j).

        8. If the screener at VSH deems the EE appropriate you will be directed to first look for a 72 hour hold bed, these are located at FAHC, CVH, Windam, & Rutland. Speak with psych admitting at FAHC & CVH regarding the availability of a 72-hour hold bed, if neither hospital has one available at that point request the screener place the CT at Waterbury. (Explain to screener that Rutland & Windam are very distant & arranging transport becomes difficult.)

        9. Document carefully - you may be asked to testify in support of your actions.

        10. EE forms are located in Molly’s office in the ER. In the narrative section, include:

          1. History of the presenting problem

          2. Documentation of mental illness

          3. Documentation of danger to self or others

          4. Relevant history, including information gathered from other sources

          5. Documentation of community alternatives considered and reasons for their rejection

          6. Mental Status Examination (general observations, not necessarily formal Mini-MSE)

          7. Preliminary diagnosis

          8. Justification of need for involuntary hospitalization

      5. Transportation

        1. From hospital to hospital, an ambulance must be used & OBRA form must be signed by a M.D.

        2. Sheriffs must be called for transportation to VSH or 72-hour hold

        3. FGIMH staff may transport to 22 Upper Welden or Transitional Housing

          1. Two staff members are preferred

          2. At least one staff member must be of the same gender as the CT

          3. Be certain that your car insurance policy is not lapsed and is approved by the agency - the agency will help to pay for some levels of coverage

          4. Observe all safety standards, including seat belts

        4. Taxis are often an option, which can be charged to the agency (if approved), Medicaid, or out of the client’s pocket. Taxis are used to transport clients within our catchment area to private residences or respite placements

        5. When patient is to be transported home or to a private dwelling, you must stay with the patient until you see the patient get in the car and you can identify (& speak to) the person with whom the patient is riding

  2. Emergency Room Consults

    1. Consult must be requested by a doctor

    2. Maximum response time for ER consults is 30 minutes

    3. Is the client intoxicated?

      1. You may request a Breathalyzer from the nursing staff, or a blood test (which must be ordered by a doctor) to determine Blood Alcohol Content (BAC). If Breathalyzer BAC is > 0.08 but only marginally, request a blood test to improve accuracy

      2. You cannot accurately evaluate a patient with a BAC greater than 0.08, although you may wish to perform a preliminary interview

      3. If the patient has a BAC > 0.08, the ER staff may call CDAS/Harbor Club detox worker or the police, in order to have the patient placed in protective custody ("PC’d").

      4. Refusal to submit to a Breathalyzer or blood test is considered to be sufficient grounds for PC

      5. If the patient is possibly a risk for harm, you should arrange to see him/her immediately upon his/her release from PC. Clients can be held in PC for up to 24 hours, although this is often not feasible

        1. Male patients are PC’d at Northwestern Correctional Center in St. Albans, and are followed up by FGIMH

        2. Female patients are PC’d at a correctional center in Burlington, and are generally followed up by Howard Crisis if MH issues need attention

      6. Note that the typical rate for alcohol to be processed is approximately 0.02 per hour

      7. If the patient has a BAC >0.00 but <0.08, he/she should be evaluated, although your report should indicate that your assessment is tentative due to the presence of alcohol

      8. If appropriate, refer clients to an outpatient program:

        1. CDAS

        2. Day One / Bridge

      9. Or to a residential program:

        1. Brattleboro Retreat

        2. Maple Leaf Farm

        3. Canterbury Farm

        4. NOTE: Clients must be screened by Act One or CDAS workers in order to be placed in a residential facility

    4. Gathering data about the patient

      1. It is often helpful to speak to those who have been involved with bringing the patient to the ER, such as EMTs, police, etc. in order to obtain background information, initial impressions, and an objective chronology of events directly leading to the need for mental health intervention

      2. Always read the nurse’s notes, the face sheet, and if present, the patient’s file for further background

      3. If possible, interview those family or friends who accompany the patient to the ER

      4. If the patient is an assault risk, see them in the trauma room, in the main ER, or in the presence of a police officer

      5. When interviewing the patient, focus on limited issues, including:

        1. The history of the presenting problem

        2. The degree of suicidality / homicidality, or other danger of harm to self or others

        3. The possible options for an effective plan, and the patient’s ability to comply with it

        4. The patient’s mental status

      6. If the client is previously unknown to the agency, a more thorough assessment may be needed, including employment history, family history, medical history, mental health history, legal history, relationship history, etc

      7. If a patient presents a clear threat to leave the interview, and you are concerned regarding this patient’s safety, the switchboard (dial "0") can have the police brought to the ER. The police have also been known to assist in tracking down unsafe patients who have fled

      8. When the interview is complete, the ER staff will have to administratively discharge the patient. You will need to fill out a Consult Sheet, located on the middle shelves directly behind the nurse’s station. Keep the yellow copy of the consult sheet, and a photocopy of the "Face Sheet" for FGIMH records. Write consult sheet in general SOAP format, including presenting problem, brief history, prelimary diagnosis, and disposition.

      9. All dispositions must be reviewed with the attending ER physician

      10. Check the ER "Face Sheet" for insurance information, depending on insurance company authorization may need to be obtained immeadiately or during the next business hours.

  3. Phone Screenings

    1. The following information is necessary

      1. Name, phone number, date of birth

      2. Referral source

      3. Medications

      4. Primary physician

      5. Presenting problem

      6. Suicidal ideation

      7. Treatment goal(s)

      8. Insurance (you may need to obtain pre-certification from insurer)

    2. The following information is recommended

      1. Stressors

      2. Supports

      3. Substance use

      4. Previous MH History

        1. Hospitalizations

        2. Suicide attempts

        3. Previous FGIMH or other MH treatment

        4. Family history of mental illness / suicidality

      5. Medical issues or history

      6. Whether the client is seeking to obtain a legal or other advantage by coming to FGIMH -- i.e. Why is the client calling for an appointment now?

    3. Based on the above criteria, determine whether the case is emergent, non-emergent, or inappropriate

      1. Emergent - CT poses imminent safety risk

        1. Give rapid appointment in clinic with Emergency Clinician

        2. Make safety plan as appropriate (document!!)

        3. May need to be seen immediately face-to-face and evaluated for hospitalization

      2. Non-emergent

        1. Refer to Outpatient Coordinator for intake appointment or schedule for an immediate care appointment with yourself on next non-crisis day

        2. Explain use of emergency service and advise they be used PRN

        3. Court ordered Cts will need to present court order, treatment goals, agree to sliding fee scale and payment before session before an intake is scheduled

      3. Inappropriate

        1. FGIMH does not offer treatment for sex offenders.

        2. Unless clients are court ordered, we will not offer services to those people who are opposed to receiving them

        3. Clients seeking outpatient services must have a clear, realistic treatment goal

        4. Cts seeking only psychiatric services are inappropriate, psychiatrists may be willing to provide a one-time consult for a referring physician, but their caseloads are too heavy for them to follow Cts alone. Cts seeking only psychiatric treatment shoudl be redirected to private psychiatrists in Burlington or their primary physician. In the event that another MD does request consult by psychiatrist speak directly with the psychiatrist regarding request. All records must be sent also.

        5. If primary concern is substances, refer to CDAS - client will need to be "clean and sober" for 3-4 weeks before assessments are valid and medications can be considered for depression or anxiety

  4. M&S Consults

    1. Must be requested by a doctor

    2. Same procedures as ER consult, except:

      1. You are usually asked only to provide an assessment/opinion, not necessarily to devise &/or implement a plan

      2. A copy of the formal mini-MSE (used to screen for dementia) is often handy, and frequently needs to be included with your write up

      3. Generally, a more complete history is expected than in crisis situations

      4. If you have questions or concerns, you can ask to speak to the doctor who has requested the consult for clarification

      5. You should generally plan to consult with the doctor after you have completed your assessment

  5. Police, Prison, and Court Consults

    1. Inmates are not interviewed in the prison - they are to be brought to the ER, and you are to have guards in the room for your protection at all times, at your discretion

    2. Consults requested for inmates must be initiated by either the superintendent (Steve Miranville) or by a doctor

    3. Male clients who have been PC’d to the Northwestern Correctional Center (NCC) do need to be interviewed at NCC prior to release, but a guard should be present at all times

    4. Occasionally consults need to be done in police barracks, and you may request that an officer stay with you

    5. Frequently, these consults can lead to legal difficulties for clients, and you should speak to police prior to interview regarding probation/parole status, possibility of charges being pressed, etc. in order to formulate appropriate plan

    6. There are times when police call re: a safety concern about a CT refusing to come to police station or ER and that police have no legal grounds to transport against their will. When this situation arises it is necessary to accompany the police to the location of the CT and perform your safety assessment there. If CT meets EE criteria but persists in their refusal to be transported to a place where a psychiatrist can evaluate it will be necessary to do a warrant. Consult with VSH screener also. Police can take CT into custody while the warrant is being pursued. Warrant paper work must be completed and presented to a judge. If judge approves warrant CT should be transported to VSH by sheriff.

    7. You may occasionally be requested to perform an assessment at the courthouse on a person awaiting trial. This request must come from the paralegal staff at Vermont State Hospital. You should you use previously described EE criteria during cour assessments also.

  6. 22 Upper Welden & Transitional Housing (174 No. Main)

    1. Often staff at these facilities call to let us know that clients are acting strangely, or that they feel the client is becoming out of control. These situations can usually be de-escalated by simply speaking to the client, asking them to stop the aggressive behavior, asking them what they need, or offering to report their concerns to their case manager. Clients who become violent need police intervention.

  7. After Hours Coverage Guidelines

    1. Emergency telephone calls must be responded to within 15 minutes. The goal of emergency calls is to provide minimal support & structure and assess safety. If CT is unable to make safety contract they made need to be met in the ER for face-to-face assessment and intervention. In the event that CT refuses to contract for safety and refuses to meet you in the ER you may have to accompany police to CT’s location.

    2. When ER requests a consult response time is 30 minutes, see above section on ER consults.

    3. There is currently a back-up system in place, utilize your back-up person sparingly. When in the middle of an intervention, if the CT is under control and in a safe environment (ER or police station) you should continue to take call. On occasion there may be more than one consult at the ER, it is appropriate to prioritize and have Cts waiting safely in the ER or at a police station.

CHILDREN

  1. Suicidal Statements, Danger to self or others

    1. Remain at home

      1. Parents / guardians must guarantee safety

      2. You should review safety precautions

        1. Guns removed from home

        2. Knives, sharps, medicines, cleaners out of reach of child

      3. Child may require 24 hour supervision

      4. This plan must agree with your clinical judgment regarding a safe placement for the child

      5. Appropriate programs may include

        1. New Horizons (especially for "chronic crises")

        2. New Connections - Family Center program geared towards keeping families intact, geared especially toward teenagers

        3. Children’s Case Management

        4. Outpatient services

        5. Coordinated Service Plans

        6. The Continuum Program, for children aged 12 - 19, a day-only program in Essex Junction, specializing in conduct disorders, cases of abuse, eating disorders

    2. Hospitalization

      1. The child must meet the same criteria for hospitalization as an adult.

      2. Most placements require the child be voluntary. Baird is an exception, they are willing to take involuntary children under the age of 12. Involuntary teenagers can be EE’d to Brattleboro Retreat, you must follow same procedure as for an adult EE.

      3. At this time there is not a crisis bed for children in Franklin or Grand Isle Counties. For children who are known and being serviced by the agency and do not pose an imminent danger but can not be managed at home it is sometimes appropriate to consider respite through FGIMH. Randy Clark is Respite Coordinator. This option should be cleared by Katy Thompson.

      4. Child must not be able to remain safely at home

      5. Be able to clearly document what dangerous behaviors or statements the child has demonstrated in your presence, as well as those reported by interested parties

      6. The child must pose a danger to self or others

      7. The danger must be immediate, not based on past events

      8. Resources:

        1. Baird (Burlington), for children aged 6 - 14

        2. NFI (Burlington), for children aged 13 - 17

        3. Cheshire (New Hampshire), for ages 10 to adult

        4. Brattleboro Retreat - private insurance only, costs $1,000 a day. Katy &/or Russell Frank can arrange to have this fee waived for Medicaid children or for children deemed appropriate for the emergency bed

        5. Katy Thompson, FGIMH Clinical Director

        6. Russell Frank, CRC Director, Vermont

        7. If the child is already in SRS custody check to see if they are serviced by the CAP team, an NFI affiliated team. CAP team has an on site after hours worker & access to SRS respite beds.

  2. Family difficulties / SRS

    1. If family refuses to take child home, situation has become unmanageable, and child is not appropriate candidate for hospitalization, Social Services (SRS) needs to be considered

    2. If you learn of child abuse (physical, sexual, other) or neglect, you must report it to SRS immediately - confidentiality does not apply in this situation

    3. When parents refuse to take a child home, explain that this is legally equivalent to abandonment, and that it represents a termination of parental rights. Contact police, who will arrange a placement for the child in conjunction with SRS

    4. FGIMH does not arrange placement (finding a place for a child to stay) other than hospitalizations. This is solely the responsibility of the police and SRS

    5. If an SRS worker asks you to provide a consult for a child in custody, insist that the SRS worker remain present throughout the interview until the plan is enacted. They are often instrumental in devising plans and placements, and have legal responsibility and authority for the child If a child in SRS custody is hospitalized it is the responsiblity of SRS to provide transportation and an SRS worker must accompany child to sign child into hospital.

  3. Schools

    1. We do not go to schools to handle out of control children

    2. If child is judged to be a danger to self or others, or if a child has made statements or demonstrated behavior indicating such danger, a face-to-face interview should be held immediately at the agency

    3. If immediate face-to-face is deemed necessary, the child should be brought to FGIMH. If the child refuses to come voluntarily, the police should be contacted. Parents must be contacted, although we are allowed to speak to a child once emergently without parental consent

    4. Behavior problems do not necessarily represent a mental health crisis - there must be an emotional aspect, such as suicidality, major stressors, etc. Swearing in class or refusing to do work does not constitute a MH issue

  4. General

    1. The threshold for characterizing a situation as emergent is lower for children than it is for adults. If there is any doubt, err on the side of safety

    2. Always remember that parents represent the primary factor in the environment of a child, and should be included in any planning or changes that will effect the child. Frequently, problems attributed to children can be best addressed through working with parents

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